To define the impact of BAL data on the selection of antibiotics and the outcomes
of patients with ventilator-associated pneumonia (VAP).
Prospective observation and bronchoscopy with BAL, performed within 24 h of establishing
a clinical diagnosis of a new episode of hospital-acquired VAP or progression of a
prior episode of nosocomial pneumonia (NP).
A 15-bed medical and surgical ICU.
One hundred thirty-two patients hospitalized for more than 72 h, who were mechanically
ventilated and had a new or progressive lung infiltrate plus at least two of the following
three clinical criteria for VAP: abnormal temperature (> 38 degrees C or < 35 degrees
C), abnormal leukocyte count (> 10,000/mm3 or < 3,000/mm3), purulent bronchial secretions.
Bronchoscopy with BAL within 24 h of establishing a clinical diagnosis of VAP or progression
of an infiltrate due to prior VAP or NP. All patients received antibiotics, 107 prior
to bronchoscopy and 25 immediately after bronchoscopy.
Sixty-five of the 132 patients were BAL positive (BAL[+]), satisfying a microbiologic
definition of VAP (> 10(4) cfu/mL), while 67 were BAL negative (BAL[-]). The BAL(+)
patients had no differences in mortality, prior antibiotic use, and demographic features
when compared with the BAL(-) patients. More of the BAL(+) patients (38/65) satisfied
all three clinical criteria of VAP than did BAL(-) patients (24/67) (p < 0.05). A
total of 50 BAL(+) patients received antibiotic therapy prior to bronchoscopy, and
when this prior therapy was adequate (n = 16), as defined by the results of BAL, then
mortality was 38%, while if prior therapy was inadequate (n = 34), mortality was 91%
(p < 0.001), and if no therapy was given (n = 15), mortality was 60%. When therapy
changes were made after bronchoscopy, more patients (n = 42) received adequate therapy,
but mortality in this group was comparable to mortality among those who continued
to receive inadequate therapy (n = 23). A total of 46 of the 65 BAL(+) patients died,
with 23 of these deaths occurring during the 48 h after the bronchoscopy, before BAL
results were known. When BAL data became available, 37 of the 42 surviving patients
received adequate therapy, but their mortality was comparable to the patients who
continued to receive inadequate therapy.
Patients with a strong clinical suspicion of VAP have a high mortality rate, regardless
of whether BAL cultures confirm the clinical diagnosis of VAP. When adequate antibiotic
therapy is initiated very early (ie, before performing bronchoscopy), mortality rate
is reduced if this empiric therapy is adequate, compared to when this therapy is inadequate
or no therapy is given. If adequate therapy is delayed until bronchoscopy is performed
or until BAL results are known, mortality is higher than if it had been given at the
time of first establishing a clinical diagnosis of VAP. When patients were changed
from inadequate antibiotic therapy to adequate therapy, based on the results of BAL,
mortality was comparable to those who continued to receive inadequate therapy. Thus,
even if bronchoscopy can accurately define the microbial etiology of VAP, this information
becomes available too late to influence survival.